Is there one perfect way to start solids?
Over the last several years a new feeding style for starting solids in infants has emerged, Baby Led Weaning (BLW). BLW involves providing the infant pieces of food that can be picked up and encourages the infant to self-feed at around the age of 6 months, skipping purees. In some circles it has led to debate as to which way is better BLW or starting puree foods from a spoon.
This debate has led to some believing that purees are somehow not nourishing or indicates a child is not really being fed the right way.
Can infants start solids by skipping puree foods?
In late 2017 there was paper published that reviewed previous studies on BLW that were published between 2010 and 2016. One of the factors examined was the feasibility of BLW. One study showed a majority of infants were able to reach for foods by 6 months of age, but this may be delayed in some infants with special health care needs (poor weight gain, feeding difficulties, sensory issues, and developmental delay).
My concern for families with special needs children
My concern over heavily encouraging BLW is for the infants that are not typically developing and how an overall message of puree foods not being optimal may lead to parents of special needs infants feeling even more on the outside of parenting circles. I have become more aware and sensitive to this due to the fact I have a very good friend who has a child with cerebral palsy. When her son was 6 months old he was visibly not meeting the milestones of his peers, stayed on puree foods longer than his peers, and today at age 7 he still requires assistance to be fed as he is not an efficient self-feeder.
She has expressed to me that many times people judged how she was feeding her son even though she was providing the food that was developmentally appropriate and he was growing and thriving.
Differences between BLW and Starting with Puree Foods
In studies where infants followed BLW they ate mostly whole food at around 6 months of age and a majority of these infants were breastfed (although formula fed infants also follow BLW). When families used the traditional method of starting with puree foods from a spoon the introduction of food is closer to 4 months of age. Following review of the studies there was some evidence to support that BLW leads to better appetite control, more variety in the diet, improved motor skill development, desired weight, and decreased fussiness (as perceived by parents). However, these outcomes are also associated with breastfeeding, which makes one wonder if the benefits are due to the foods provided or influenced be the fact the infant is breastfed?
Concerns of Healthcare Providers
As BLW has gained popularity some healthcare providers have expressed concern. There is concern that BLW will not provide important nutrients, such as iron and energy dense foods, for this stage of life. This concern stems from the fact that infants this age may not have the efficiency or skill to take in adequate amounts of table food. An additional concern is that infants will choke on the food offered. Research has been done on Baby Led Weaning vs. spoon feeding, but since it is fairly new on the scene of infant feeding more needs to be done.
One study addressed these concerns. The BLISS study (Baby Led Introduction to Solids Study), used a modified method that addressed concerns healthcare providers had about BLW. Families were educated specifically on the correct type and texture of food to provide, safety precautions at meal time, and were told to specifically offer 3 types of food at each meal (an iron rich food, an energy rich food, and a fruit or a vegetable). The group following the BLISS protocol was compared to a control group of infants fed traditionally with puree foods.
The study concluded that infants on the BLISS approach were not at more risk for choking, but infants from both the BLISS group and the control group were offered food that posed a choking risk, which was concerning.
Another study in the British Journal of Medicine compared infants that were fed using the BLW approach to traditional spoon feeding and the results showed that the energy intakes of both groups were the same, however, the group that followed BLW has higher intakes of saturated fat and had lower intakes of iron, zinc, and B12. Iron and zinc are noted nutrients of concern in infants. It was observed that both the BLW group and the infant’s that were spoon fed were frequently offered foods that posed a choking risk. Therefore, this may indicate that there needs to be more education on choking hazards in infants, however, the study investigators state that a limitation was that the study was small as it only had 51 infants.
Sources of Nutrients of Concern
In the first year of life all nutrients are important, but for infants the ones of concern include iron, zinc, Vitamin D, and total fat (including DHA). Iron is important for brain development and carrying oxygen to the cells. At the age of 6 months an infant’s iron needs increase to 11 mg, which is why it is important to introduce iron rich foods early. Zinc is crucial for normal growth and for the immune system. An infant needs a constant intake in order to maintain their stores. Vitamin D helps increase the absorption of calcium for improved bone health and having adequate amounts is thought to play a part in preventing chronic disease. Vitamin D is not highly available in food sources and with the recommendation to use sunscreen the sun may not be a great source; therefore, a supplement may be needed. In fact, the American Academy of Pediatrics recommends that most breastfed infants and formula fed infants (drinking less than 32 ounce of formula) get a vitamin D supplement. Fat is important to infants because it is a concentrated source of energy (9 calories per gram vs 4 calories per gram in carbohydrates and protein) and it is important for brain growth. DHA is a type of fat that is involved in eye and brain development in the first 2 years. Below you will find recommended sources of these nutrients:
Iron- Animal Based- Eggs, Beef, Chicken, Light tuna, Shrimp; Plant Based- Iron Fortified Cereals, Beans, Lentils, Soybeans, Spinach
For the plant-based sources of iron to be absorbed better offer those foods with a food rich in vitamin C-Berries, Tomato products, Banana, Broccoli, Red Peppers, Oranges, Cantaloupe, Pineapple
Zinc- Beef, Dark meat chicken, Beans, Whole milk yogurt, Fortified cereals and grains
Vitamin D- Salmon, Canned tuna, Fortified cereals, Liquid supplements, and Sunlight (This cannot be considered a reliable source as many infants are not in the sun at peak times of exposure and sunblock is recommended).
Fat- Whole milk yogurt, Cheese, Butter, Avocado, Nut butters (discuss introduction with physician), Vegetable Oil (this can be used to prepare soft cooked vegetables and pastas)
DHA- Fish- salmon, tuna, and trout, Fortified eggs, Fortified infant formula
Moving Forward: What families and caregivers need to take away
The best thing about BLW is that is seems to encourage self-regulation of appetite. This can also be done by teaching parents what signs to look for when an infant is full.
Signs of fullness include an infant turning their head to a spoon or food offered, disinterest in eating, increased fussiness, and pushing food or spoon away with hand. Along with educating families on hunger cues they should also be encouraged to not force feed if the infant is refusing.
I think BLW is great for families of typically developing children with no special health needs, but I am not ready to say that is how it has to be for everyone. I believe educating on the types of foods to provide first to provide the essential nutrients is important for all families regardless of how solids are introduced. Teaching parents how to monitor for fullness and avoid overfeeding would also be inclusive of all families. More individualized teaching should occur based on the child’s ability and development
In the changing world of infant feeding it does not have to be BLW vs. puree foods. There is no one perfect way to start solids on all infants, but there is a perfect way for each infant based on development and ability.
If you have questions about starting solids on your baby, I am happy to help.
Post updated on May 17, 2019